Pure transvesical NOTES appendectomy using a 5-mm rigid laparoscope: a feasibility and survival study with porcine models

Abstract

Previously, the authors demonstrated the feasibility of a pure transvesical natural orifice translumenal endoscopic surgery (NOTES) for uterine horn resection (UHR) using a rigid ureteroscope in swine as an appendectomy model. However, visualization was poor, and there was room for improvement. The authors have assessed the feasibility and safety of a revised technique that uses a 5-mm rigid laparoscope. Eight operations on four female pigs (35-40 kg) were performed as a proof of concept study. Four right-side operations were performed in a survival model. The surgical procedure was similar to the original technique. However, the rigid ureteroscope was replaced by a 5-mm laparoscope after modification of the access system. In addition, the clipped metal threads used for bladder closure were easily placed with a long 13-gauge needle. In the survival model, a Foley catheter was placed for 1 day. The new technique provided considerably better visualization and operability than the original technique. The mean total operative time was 96.6 ± 18.2 min, and the mean estimated blood loss was 15.0 ± 13.5 ml. On postoperative day 3, pig 2 in the survival study died of peritonitis resulting from a small bowel injury. The lab results for the other pigs demonstrated no adverse events and tolerable immune responses. Necropsy showed complete healing of the vesicotomy. The revised transvesical NOTES UHR technique improved the outcomes and feasibility of the original technique. This approach may be translatable to human appendectomy procedures in the future.